Dr Paul Yesudian is not a typical dermatologist.
This particular doctor is outspoken and keen to uncover the facts within a very specific sub-segment of medicine.
Dr Yesudian believes that treating people with skin of colour is a subject that requires better training and education amongst his peers and trainee medics. He has over 60 publications in peer-reviewed journals and has co-authored chapters in two major textbooks. He was also given the title of Honorary Professor by the University of Madras in 2009 and is a medical advisor to Melanoma UK.
We recently attended a seminar presented by Dr Paul where some of what he said took us by surprise. In our pursuit to make products, educate and inspire all people to take care of their long-term skin health through daily skin protection, we wanted to share his knowledge and advice in this week's LifeJournal.
How is skin colour defined?
This is the starting point: defining skin types.
In the 1970s, two photo-biologists called Fitzpatrick and Pathak classified skin into six groups.
The Fitzpatrick-Pathak classification
In simple terms, Fitzpatrick and Pathak classified groups 1-4 as types of white skin (think red head through to Mediterranean), type 5 as Asian skin and type 6 as African and Afro-Caribbean skin. They came up with this classification by asking people how their skin responded to the sun.
In reality, there's overlap and people don't always fit within one 'type'. But to this day, this classification is used as a reference point by dermatologists, understanding that it may have its limitations.
For the purpose of this article, 'skin of colour' can be considered to be people with skin types 5 and 6 (and maybe some darker type 4s).
What gives skin its tone?
A natural pigment called melanin is what gives humans such an amazingly broad and rich range of skin tones.
Melanocytes are cells in the skin that produce melanin. We all have very similar numbers of melanocytes regardless of skin type but in people with skin of colour, melanocytes are more reactive causing them to produce more melanin, that gets distributed equally, giving the skin a darker pigment.
Melanin is the body's natural defence mechanism against UV light. It's the truest definition of 'natural sunscreen'. The amount of melanin within Afro or Afro-Caribbean skin gives an equivalent SPF of 10-13, providing an inherent level of UV protection.
Quick recap of skin cancer incidence for context
According to Dr Yesudian, skin cancer is the most common malignancy in the UK and US. 30% of all cancers in white people can be attributed to skin cancer.
In stark contrast, skin cancer accounts for 2-4% of cancers in people with Asian skin and 1% in people with African skin. On the face of it, skin cancer is 70x more likely to occur in people with white skin.
However, Dr Paul was quick to point out that medical and dermatological textbooks and medical training almost exclusively document white skin. Images in books always show diseased white skin and in a science that's as visual as dermatology, that's not good enough in today's world.
The point is incidence rates are clearly lower in skin of colour but statistically, that could be because it isn't always picked up. And because of that, survival rates for black people who do develop melanoma have a much lower five-year survival rate. From 2011-15, the five-year survival rate in the United States for Black patients was 66%, compared with 90% for non-Hispanic white patients, according to a 2019 study published by the Centers for Disease Control and Prevention.
Is this the largest ever skin cancer study on skin of colour?
It's estimated that 90% of skin cancers in skin types 1-4 are caused by ultraviolet light. Typically, they occur on parts of the body that are sun-exposed. You've heard us bang this drum forever.
However, this is where things get interesting...
In December 2020, research was released in JAMA Dermatology, a monthly peer-reviewed medical journal published by the American Medical Association.
This research put forward some interesting findings following one of the largest ever studies conducted into UV exposure and the risk of melanoma in skin of colour.
If you're interested, you can read how the study was put together, how it was reviewed and its flaws but the conclusion was that the association between UV exposure and melanoma in skin of colour is weak (as compared with the 90% causal effect in white skin).
So, when it comes to skin cancer in skin of colour, what are the risk factors?
The three most common types of skin cancer in skin of colour
We explain the different forms of skin cancer here so to avoid repetition, we'll jump straight into it.
Squamous Cell Carcinoma (SCC)
This is the most common skin cancer in people with skin types 5 and 6.
SCC does NOT present in areas of the body that are sun exposed suggesting that sun or UV exposure doesn't play a role in causing SCC. This is contrary to white skin where UV light is the main cause for SCC.
The causes or triggers for SCC in people with skin of colour are (1) chronic scarring and (2) chronic inflammation. If you have either of these, you should pay close attention to changes in the skin at these sites.
If you see any of the following symptoms around scarred of inflamed sites, consult a doctor:
- Starts as a small spot
- Can be tender
- Grows rapidly
- Forms an ulcer in the centre as it gets larger
For example, if you have an insect bite that isn't healing and has some or all of the symptoms above, it's worth checking out. Don't treat these symptoms as trivial and make sure your doctor takes care. SCC in skin of colour is often missed and caught too late explaining why SCC metastasis rates are 20-40% in skin of colour vs. 1-2% in skin types 1-4.
Treatment is simple: cut it out and perhaps radiotherapy if the site is hard to reach.
Basal Cell Carcinoma (BCC)
This is the most common skin cancer in the world. However, in type 6 skin, SCC is most common.
Regardless of skin type, BCC is caused by ultraviolet light exposure, it's just that BCC is rare in skin of colour. But that's not to say we should write it off because it still exists.
In skin of colour, BCC is commonly seen on areas of the body that get sun exposed. If you see any of the following symptoms, consult a doctor:
- Starts as a transluscent lesion
- Grows slowly (3-4mm per year)
- More than 50% can be pigmented which is very different to how it presents in white skin (often causing mis-diagnosis)
- Sits on the surface of the skin
Again, treatment is simple: cut it out (95% cure rate), a cream can be used on superficial lesions and/or perhaps radiotherapy.
Melanoma
This is the most important skin cancer because it's so lethal and early diagnosis can save lives.
While incidence of melanoma in skin of colour is lower than in white skin, it does occur. The fact that it's rare means it can be missed, mis-diagnosed or, quite commonly, diagnosed too late explaining why death rates are so high for people of colour with melanoma.
There are some very specific risk factors to be aware of when it comes to melanoma in skin of colour:
- Anything that causes scarring of the skin (trauma, radiation, immunosuppression)
- Pre-existing pigmented lesions
Make note that UV light and genetic factors are NOT melanoma risks in skin of colour (again, contrary to in white skin).
Typically, melanoma in skin of colour presents differently, precisely because of these reasons. For example, it doesn't necessarily show up on sun-exposed parts of the body. It's more common to see melanoma on skin of colour in sun-covered, and hard-to-see acral or mucosal areas (under nails, bottom of feet or hands, inside the mouth). More than 90% of people with skin of colour have at least one mole and they're most commonly positioned in the these areas. These pre-existing moles can form dark patches that lead to melanoma.
Again, surgery is the gold standard when it comes to treatment. Melanomas should be excised as early as possible.
What does all this tell us?
Firstly, skin cancer in skin of colour is rare but it does exist so preventative measures are paramount.
Starting at grass roots, medical textbooks and training needs to be updated. The next generation of doctors must be better-equipped to diagnose all skin diseases in all skin types.
We passionately believe governments, health services and medical professionals have a responsibility to provide very specific information because skin cancer in skin of colour manifests in very specific ways.
Don't be complacent
We're seeing more and more people with skin of colour show up in the LifeJacket world whether that's followers, athletes or people attending our skin protection training courses.
This is fantastic to see because we feel the principle of 'protect and detect' applies to everyone. Apart from basal cell carcinoma (which is rare in skin of colour), UV light is not a significant risk factor in the same way it is for white skin. But, it is still a risk factor for BCC. And going back to the Fitzpatrick-Pathak classification, many of us bridge across two skin types.
Finally, in terms of detection, routine self-examination is important. But it's different. The usual ABCDE mole check should be used alongside a regular examination of hands, feet, nails and the mouth area.
We know this can be a delicate subject but we hope it helps and gets you to take your skin health seriously.
